NPfIT: The Biggest Computer Programme in the World Ever ! Sean Brennan Clinical Matrix.

NPfIT:The Biggest Computer

Programme in the World

Ever !

Sean BrennanClinical Matrix

Why do the cows in the Isle of Man have better computers that

the NHS?

But…………………..

• Daisy’s Record is a by-product.• The Primary objective is to milk her.

Why does my dog have a better electronic health record than I

have?

Clinical History

Doggie Health Record

So why do we need clinical IT?

Today in the NHS (England)

• Will spend £170 million• £2000 every second• £10 million settling litigation claims• 110 people will die due to ‘adverse events’• 1230 people will suffer an adverse event• 270 people will catch a hospital acquired infection• £2.8 million on treating patients who have MRSA• £1.3 million on treating patients who have had an

adverse drug event

Today in the NHS (England)

• 200,000 people will get help in their home from the NHS• 1.2 million will visit their GP’s• 160,000 will be treated in NHS Outpatients• 140,000 will visit an NHS dentist• Over 1400 babies will be born• NHS Direct will receive 3,500 calls seeking advice• Labs will perform millions of tests

The NHS is a very BUSY organisation.• 3 million critical processes each and every day.• If totally supported by electronic records that would be approx 30 MILLION30 MILLION new transactions

each day!

So

• Computerising the NHS is a very big and very difficult project.

• But lets NOT just add technology to existing workflow…….Isn’t there a better way?

Spanish Brasero – wasted opportunity?

A.A. Milne 1926

Illustration E.H.Shepard 192614

“Here is Edward Bear,coming

downstairs now, bump, bump, bump,

on the back of his head, behind

Christopher Robin. It is, as far as

he knows, the only way of coming

downstairs, but sometimes he feels

that there really is another way,

if only he could stop bumping for

a moment and think of it”

It’s about change

• We need to change the way care is delivered

• IT enables change to happen• The current model is no longer

appropriate

Visits GP/practicenurse

Visits OutpatientsAttends A&E

Is visited at home by care worker/midwife etc

In-Patient

Visits OutPatients

VisitsGP/practice

nurse

Attends A&E

Calls NHSDirect

Uses theHome HealthCare Guide

Calls OOHservice

Is visited at homeby GP, nurse, social

/ care worker,midwife etc

Goes to thepharmacy

Visits thedentist

Attends as

in-patient

Calls 999

Use NHSDirect.online

Visits awalk-incentre

We must use technology to support change

Not just add technology to existing ways of working

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Cluster wide Data Repository





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What does it look like?

eBooking PDS PSIS eTP

Transaction Messaging Service


What will it do?NASP

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eBooking PDS PSIS eTP

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Patient IndexPACS

Prescribing &Pharmacy

Scheduling

ClinicalDocumentation

Request & OrderCommunication

Decision Support

Assessment

ResultsReporting

DocumentManagement

eBooking

Care Management

Care Pathways & Planning

User Tools

Prevention, scheduling

& surveillance

So what’s in it for you and your patients?

•This is the biggest national clinical change programme ever carried out in the NHS

•It will affect you and all your clinical colleagues•It will impact the way that you practice and improve the way

you treat your patients by:

– Ensuring that the right information is always available at the point of care

– Making it easier and faster to book appointments order tests and see results, anywhere

– Helping to ensure consistent good practice treatments– Reducing prescribing errors– Stops the paper chase. Making huge savings on the 30% of

all NHS costs that are associated with recording, transporting, storing, and looking for information!

OK – so what do I get out of it?

• Access to knowledge/guidelines• Real-time decision support• Access to ALL the patients information• Reduction in administrative data collection• Provide clinical information for secondary

analysis• Reduce inappropriate referrals• Plan discharge• Opportunities to re-design the service

NCRS: What are the benefits?

Benefits……….

• Access to clinical knowledge• Access to all the patients information• Better communications• Decision support• Easier ordering and prescribing• Access to digital images (X-Rays)• Care pathways and protocols• Quality clinical information for audit and research

Hospital discharge letters

• Illegible• Written in haste• Arrive two weeks after discharge

Benefits: Access to knowledge

T’Internet

The Good, the Bad and the Ugly

Benefits

Reduce Illegibility

Illegible Writing kills Patients!

• Doctors writing illegibly are still killing patients Advise doctors to write in CAPITAL LETTERS• It is writing in lower case in a hurry which

causes mistakes Medical Defense Union in BMJ 1992;305:604

Benefits

Decision Support

Prescription Error Rate

Admission Drugs - 24% patients had 1 error (or more)

- - 2 items in error per patient

Discharge Drugs - 19% discharge prescriptions had error

- - 1.4 items in error per patient

Total Error Rate - 21.5% patients had error in prescription on admission / discharge

- 1.7 items in error per patient

Drug Errors: Causes

• Human Factors 42%• Labelling 20%• Communication 19%• Name Confusion 13%• Package Design 6%

Advantages of Electronic Medicines Administration

• Clarity• Schedule compliance• Audit trail• Alerts/Warnings

But……..• Computer errors on the increase!

– 46% errors in transcription and documentation phase– 36% errors at drug dispensing– 13% errors at prescription phase– 4% errors at drug administration

• Automation does not equal safety. Training is an issue

• Don Detmer: Properly structured automated systems can reduce error rates substantially. However, simply installing an automated system will not magically eliminate errors.

Benefits:

Warnings

Useful Warnings !

• The drug you are about to give the patient will react with one they are already on.

• The dose you are about to give the patient is incorrect for their body mass.

• On bottom of Coke bottles –– Open other end

What will make it work?

• What’s in it for me ?– Benefits to me as a clinician– Benefits to my patients– Benefits to my organisation

• Is it easy to use?• Is it responsive? (i.e. quick!)

Making it easy to use

The Interface: The London Underground

Ways to improve clinical data capture

User Interface

• Touch Screens• Handwriting Recognition• Bar Codes• OCR Forms• Light Pens• Voice Recognition

Touch Screens for clinicians

• In certain conditions excellent– Operating Theatres– Sterile Stores– Reception areas

Bar Codes

• Invented in1948 by Bernard Silver and Norman Woodland

• 1949 first patent issued 1952• Trial by Bar Codes?• But…….was it the Irish who invented it?

Bar Codes: Uses in healthcare

• Drugs• Laboratories• Meals• Fluids• Positive Patient ID• X-Ray films

Light Pens

• Rapid• Easy to use• Used at Wirral • Removes need for keyboard• Rapid (Did I say rapid?)

Optical Character Recognition

• Useful for patients use– Complete data before consultation

• Good for surveys• Where multiple data items are collected –

Anaesthetic information in theatre• Paper is good !

Voice Recognition

• Opportunities– Radiology– Pathology– Clinician Reporting

• Discharge letters• Outpatient letters

1992 NHS IM&T Strategy

Haven’t we been promised all this before?

Why should we believe it this time?

This time…..

• Top of the office commitment• Huge increase in resources• Tight contracts• Buying a service not a single system• Local Service Providers accountable• Recognition that it is NOT just an IT project

But………………..

• Local Vs.. National• We MUST engage clinicians• We MUST be open and honest about timetable• We MUST acknowledge it is difficult AND

different• We SHOULD ensure we have the right focus• We MUST learn from history

What annoys clinicians?

• Change for the sake of change• Dodgy evidence• Quicker doesn’t always mean better• Systems that don’t fit clinical workflow• Feeding the beast• Slow systems• Not enough workstations• Interfering computers• Too many alerts• Complicated systems/poor user interface

Thank You

Merry Christmas & Happy New year

[email protected]

NPfIT: The Biggest Computer Programme in the World Ever ! Sean Brennan Clinical Matrix.

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